Please Complete the Entire Form Packet ONLINE Below

Please do NOT attempt to print or hand-write responses on this form. Hand-written responses will not be accepted.

Please make sure you have allocated enough time to complete the form entirely. You will not be able to save and return to it – the entire form packet must be completed in one session.

Step 1 of 5

Patient Intake Form: Questionnaire for New Patients

This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law.
MM slash DD slash YYYY
Address
Partner's Name
If applicable please complete the following:
Symptoms:
Please check any symptoms or experiences that you have had in the last month:
Please describe:
Symptoms:
Please check any symptoms or experiences that you have had in the last month:
Symptoms
Sexual Orientation
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Are you CURRENTLY taking PSYCHIATRIC medication?
Are you CURRENTLY taking NON-PSYCHIATRIC medication?
Medication, Dosage, First/Last time you took it, Effect of medication.
Have you been on PSYCHIATRIC medication in the past?
Medication, Dosage, First/Last time you took it, Effect of Medication
Have you been hospitalized for psychiatric reasons?
Hospital, Dates, Reasons
Have you ever attempted suicide?
Are you CURRENTLY under treatment for any medical condition?
FATHER
MOTHER
Please include: Name, Sex, Age, Whereabouts, Are you close to him/her?
During your childhood, did you live any significant period of time with anyone other than your natural parents?
Children
Please select any conditions that have been present in your relatives:
Brothers
Please select any conditions that have been present in your relatives:
Sisters
Please select any conditions that have been present in your relatives:
Father
Please select any conditions that have been present in your relatives:
Mother
Please select any conditions that have been present in your relatives:
Aunt/Uncle
Please select any conditions that have been present in your relatives:
Grandparents
Please select any conditions that have been present in your relatives:
Have you been married previously?
Have you served in the military?
Are you currently employed?
Please include: Type of Job, Dates, Reason for Leaving
Have you ever been arrested?
Do you have a religious affiliation?
Have you ever been abused?
Marijuana
Cocaine
Crack
Heroin
Methamphetamine
Ecstasy